GW1-2021-07627_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM 'to DESCRIPTION
Well Contractor Name 140 ft 645 f`
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAIIIETEii THICKNESS MATERIAL
Company Name 0 f` 118 fL 6.25 in• SDR21 PVC
0458 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TIUCKN-ESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ..I7.F ROSM REE TO DIAMETER +SLOT SIZE THICKNESS MATERTAL
Agricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f`• 20 ft- Grout Poured
Monitoring pRecovery ft. R.
Injection Well: ft. ft.
Aquifer Recharge )Groundwater Rcmediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRTPTTON color,hardness soil/rock type,grain slu etc.
0 f` 113 ft• Dirt
4.Date Well(s)Completed: 6-30-21 Well ID# 113 f`• 645 ft• Rock
5a.Well Location:
Jonathan Setzer Jason Wood
Facility/Owner Name Facility ID#(if applicable)
Pepper Bush, Wilkesboro, NC 28665
Physical Address,City,and Zip ft. ft. IGGQS
Wilkes 21.REMARKS e
0
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C 'fixation:
36' 12.947' N 081' 20.777' W
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well ntractor Date
By signing this farm.1 herebv cenifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 1 SA NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a
Ifthiv is a repair,fill out known well consnvc•tion information and explain the nature of the copy of this record has been prnvided to the well mvner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 645 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@w Inn') construction to the following:
10.Static water level below top of casing: 140 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 2/3 cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016